Faculty of Health Science “Breaking the silence” Interpersonal violence and health among Sami and non-Sami. A population-based study in Mid -and Northern Norway Astrid M.A Eriksen Astrid M.A Eriksen A dissertation for the degree of Philosophiae Doctor – Month 20xx Acknowledgements Writing this thesis has not only been challenging, but also very instructive. It has been a privilege for me to have the opportunity to carry out this research. First of all, I sincerely thank all who participated in the SAMINOR 2 questionnaire study! Then my gratitude goes to many people and Institutions. I thank the Sami National Centre for Mental Health and Substance Use (SANKS) and Northern Norway Regional Health Authority (Helse Nord) for funding the PhD-project. I would also like to extend my gratitude to SANKS for providing my main supervisor, Cecilie Javo, and including my research in their many seminars in Sami communities. I am very grateful to be part of the network at The Sami Centre for Health Research, University of Tromsø- the Arctic University of Norway, which also generously made data available for me from the SAMINOR 2 questionnaire study. I would like to express my appriciation to Ann-Ragnhild Broderstad as the head of Sami National Centre, senior engineer Marita Melhus for providing their helpful advice, and postdoctor Bent-Martin Eliassen for helpful methodological reflections and encouragements. I would like to express my sincere appreciation to my supervisors for their individual academic guidance. Professor Berit Schei, who as a visiting scholar at the Sami Centre for Health Research (UiT) then located in Karasjok, lead the development of this subproject on violence and health in the SAMINOR 2 study. As a co-supervisor she introduced me to this field of research and her extensive network in the field and freely contributed her extensive knowledge of interpersonal violence and epidemiology. Ketil Lenert Hansen, my other co- supervisor, headed the data collection for SAMINOR 2 questionnaire study, and thus provided me with detailed knowledge about the SAMINOR 2 questionnaire study. He has also freely shared his epidemiological expertise with me. Finally, Cecilie Javo, my main supervisor and Professor Tore Sørlie, have shared their profound insight into research on Sami health and the consequences of trauma on people`s lives, witch has inspired me. So have their enlightening discussions and constructive comments on the writing process. I thank the Section of Preventive Medicine and Epidemiology, Department of Community Medicine and Global Health, the University of Oslo, which has been my workplace during the writing of this thesis, as well as personnel and fellow stipendiaries for a positive and instructive work environment. I am particularly grateful to the head of the department Espen Bjertness, and Hein Stigum for his statistical support and helping me developing models. I thank Maria Garcia, Ahmed Madar, Håkon Mayer, Per Nafstad, Øyvind Næss, Tone Omsland, Gerd Holmboe-Ottesen, Heine Strand and Gunnar Tellnes for their excellence in epidemiology and helpful methodological reflections and discussions. I also thank The Oslo and Akershus University of Applied Science (HiOA), Faculty of Health Science for leave with pay to finish this thesis. I thank the Sami Parliament and especially the Sami president from 2013-2016, Aili Keskitalo, for helping break the silence about interpersonal violence in Sami communities, and including my research in seminars. I am grateful to all the people in Sami communities who have placed interpersonal violence in agendas, attended seminars, and invited me to participate. Meeting so many competent Sami, working to make a change in Sami communities, have inspired me greatly. Finally, I am grateful to my extended family and friends for their enthusiastic encouragement which has been crucial in the completion of this work. Above all, I thank my wonderful husband and daughters for their boundless love, patience and support. To Øystein, my love, thank you for inspiring me, believing in and encouraging me throughout this work- and all the valuable discussions about ethnicity and methodology! I dedicate this thesis to all Sami victims of violence. I hope this work brings new knowledge to contribute to the understanding of interpersonal violence in Sami communities. Abstract This doctoral thesis is based on a sub-study of the SAMINOR 2 questionnaire study. The SAMINOR 2 study is a population based, cross-sectional questionnaire study on health and living conditions in areas with both indigenous Sami and non-Sami settlements in Mid- and Northern Norway. The SAMINOR 2 study was designed as a follow-up study of issues addressed in the original SAMINOR 1 study from 2003-2004, but was expanded to include additional health issues such as interpersonal violence and questions on post-traumatic stress (PTS). All inhabitants aged 18-69 in selected municipalities registered in the Norwegian National Population Register by 1 December 2011 were invited to participate. All data were collected in 2012. Purpose Our aims were twofold, namely (1) to investigate the prevalence of lifetime interpersonal violence and its association with socio-economic and demographic factors in two different ethnic groups: the indigenous Sami and non-Sami, and (2) to investigate and compare the association between childhood violence and psychological distress, symptoms of post- traumatic stress, and chronic pain in adulthood in these two groups. Results Sami ethnicity was found to be a risk factor for any lifetime interpersonal violence for both genders, except for sexual violence among men. The results remained significant after adjusting for socio- economic and demographic factors, as well as for alcohol consumption. A robust and positive correlation was found between childhood violence and indicators of mental disorders (psychological distress and symptoms of PTS), as well as chronic pain in adulthood, regardless of ethnicity and gender. However, the association between childhood violence and adult chronic pain was weaker and turned out to be non-significant among Sami men. Finally, a higher level of psychological distress and more symptoms of PTS were found among the Sami than the non-Sami. Childhood violence was found to mediate some of these ethnic differences in mental health problems. Conclusion The findings indicate that Sami ethnicity is a risk factor for exposure to lifetime interpersonal violence. Moreover, a consistent association between childhood violence and mental health problems and chronic pain in adulthood indicates that childhood violence represents an important risk factor for poorer health in adulthood, irrespective of ethnicity. In clinical practice, addressing childhood violence should be more focused and part of the diagnostic process for patients with adult mental health problems and unexplained chronic pain. Culturally sensitive public health preventive strategies targeting interpersonal violence in communities with both Sami and non-Sami inhabitants are warranted. Sammendrag Dette arbeidet er en del av SAMINOR 2 studien. SAMINOR 2 er en populasjonsbasert tversnittsundersøkelse av helse- og levekår i områder med både norsk og samisk bosetning i Midt- og Nord-Norge. SAMINOR 2 er delvis en oppfølging av SAMINOR 1, men ble utvidet til å inkludere flere helserelaterte tema som vold og symptomer på post-traumatisk stress (PTS). I utvalgte områder ble alle innbyggere i alderen 18-69 år og registrert i Folkeregisteret per 1 desember 2011 invitert til å delta. Selve undersøkelsen ble gjennomført i 2012. Formålet med denne studien var å undersøke forekomsten av vold og sammenhengen med sosio-økonomiske og demografiske faktorer i to etniske grupper med hhv samisk og ikke- samisk befolkning. Formålet var også å undersøke og sammenligne sammenhengen mellom rapportert vold i barndom og mentale plager og kroniske smerter som voksen. Resultat Resultatene viser at samisk etnisitet er en risikofaktor for vold, bortsett fra seksuell vold blant menn. Resultatene er signifikante selv etter justering for sosioøkonomiske og demografiske forhold, samt inntak av alkohol. Det er en robust og positiv samvariasjon mellom opplevd vold i barndom og mentale helseplager og kroniske smerter som voksen. Samvariasjonen mellom vold i barndom og kroniske smerter som voksen var derimot svakere for samiske menn. Den samiske befolkningen rapporterte høyere grad av mentale helseplager og flere PTS symptomer enn den ikke-samiske. Vold i barndom kan forklare noe av den etniske forskjellen i mentale helseplager. Konklusjon Funnene indikerer at etnisk samisk tilhørighet øker risikoen for å bli utsatt for vold. Uavhengig av etnisk tilhørighet er det å bli utsatt for vold i barndom er en viktig risikofaktor for utvikling av mentale helseplager og kroniske smerter som voksen. I klinisk arbeid bør kartlegging av vold i barndom få økt fokus for pasienter med mentale helseplager og uforklarlig smertemønster. Målrettete kultursensitive helsetiltak mot mellommenneskelig vold i etnisk delte samfunn kan være nyttig. Abstrákta Dán oasseguoradallamin lej SAMINOR 2 vuodon. SAMINOR 2 la gasskamærrásasj viesátguoradallam mij gullu varresvuoda- ja iellemdilláj sáme ja dáttja årromsajijn Gasska- ja Nuortta-Vuonan. SAMINOR 2 le muhtem mærráj joarkkem SAMINOR 1 guoradallamis 2003- 2004 rájes, valla guoradallam vijdeduváj gåbtjåtjit ietjá varresvuoda tiemájt dagu vahágahttem ja dåbddomerka vaháguvvamis åvdepájge vásádusájs (PTS). Válljiduvvam guovlojn bivddiduvvin divna